When making a differential diagnosis, it’s crucial to rule out the most dangerous/life threatening possibility first

Dr B was a primary care physician with his own practice. One of his patients was Mrs C, 74, who had been seeing the doctor for about a year. He had seen her 3 times earlier in the year for various complaints, and now, in early December, she was back in his waiting room with a new issue.

The patient was accompanied by her husband of 50 years, Mr C. The patient reported that her left hand was numb and tingling. In addition, she had trouble picking things up with that hand and difficulty turning the pages of her book. She also stated that she felt dizzy at times and that her foot had been getting numb.

Dr B examined the patient and concluded that her symptoms were due to carpal tunnel syndrome. He told Mr C that he would refer her to a specialist. When Mrs C asked the physician if he thought she might be having a stroke, he continued to say that it was clearly carpal tunnel syndrome.

The specialist confirmed the diagnosis of carpal tunnel syndrome and began treatment with steroid injections.

Two weeks after her early December appointment with Dr B, Mrs C returned to his office with a chief complaint of wrist pain. At this visit, Mrs C had high blood pressure, and also reported dizziness, constipation, increased numbness, blurred vision, and emotional distress. She had seen the hand specialist 2 days prior to this visit. Dr B believed that the steroid injection was the cause of the pain and suggested she follow-up with the specialist.

Mrs C went home and the next morning suffered an ischemic stroke. The stroke was major and debilitating and Mrs C never fully recovered. About a year later, she fell and sustained a fatal head injury.

Her bereaved husband hired a plaintiff’s attorney and sued Dr B, claiming a direct causal connection between the stroke and fall which caused Mrs C’s death, and Dr B’s medical malpractice in not noticing the signs of impending stroke. The medical malpractice theory was that Dr B failed to recognize the patient was about to suffer a stroke the day before she had it.